OBJECTIVE: To explore maternal near miss and death after emergency cesarean delivery in Somaliland, including the impact of the prerequisite for family consent.

METHODS: A facility-based, mixed-methods study was conducted to assess all maternal near misses and deaths recorded at a referral hospital that provided services to women from all regions of Somaliland. The data sources comprised a quantitative prospective cross-sectional study using the WHO near-miss tool (performed from August 1 to December 31, 2015) and qualitative interviews with 17 healthcare providers working at the referral hospital who were in direct contact with the women in labor (performed from January 15 to March 15, 2015).

RESULTS: Of the 138 maternal near misses and deaths recorded, 50 (36%) were associated with emergency cesarean delivery. The most frequent maternal complication was severe pre-eclampsia (n=17; 34%), and the most frequent underlying causes were hypertensive disorders (n=31; 62%) and obstetric hemorrhage (n=15; 30%). Healthcare providers were often prevented from performing emergency cesarean delivery until the required consent had been received from the woman's extended family.

CONCLUSION: Maternity care in Somaliland must be improved, and the issue of legal authority for consent examined, to ensure both safe and timely provision of emergency cesarean delivery. This article is protected by copyright. All rights reserved.

Somali-born women constitute one of the largest groups of childbearing refugee women in Sweden after more than two decades of political violence in Somalia. In Sweden, these women encounter antenatal care that includes routine questions about violence being asked. The aim of the study was to explore how Somali-born women understand and relate to violence and wellbeing during their migration transition and their views on being approached with questions about violence in Swedish antenatal care.

Method

Qualitative interviews (22) with Somali-born women (17) living in Sweden were conducted and analysed using thematic analysis.

Findings

A balancing actbetween keeping private life private and the new welfare system was identified, where the midwife's questions about violence were met with hesitance. The midwife was, however, considered a resource for access to support services in the new society. A focus on pragmatic strategies to move on in life, rather than dwelling on potential experiences of violence and related traumas, was prominent. Social networks, spiritual faith and motherhood were crucial for regaining coherence in the aftermath of war. Dialogue and mutual adjustments were identified as strategies used to overcome power tensions in intimate relationships undergoing transition.

Conclusions

If confidentiality and links between violence and health are explained and clarified during the care encounter, screening for violence can be more beneficial in relation to Somali-born women. The focus on “moving on” and rationality indicates strength and access to alternative resources, but needs to be balanced against risks for hidden needs in care encounters. A care environment with continuity of care and trustful relationships enhances possibilities for the midwife to balance these dual perspectives and identify potential needs. Collaborations between Somali communities, maternity care and social service providers can contribute with support to families in transition and bridge gaps to formal social and care services.

Background: Political violence and war are push factors for migration and social determinants of health among migrants. Somali migration to Sweden has increased threefold since 2004, and now comprises refugees with more than 20 years of war experiences. Health is influenced by earlier life experiences with adverse sexual and reproductive health, violence, and mental distress being linked. Adverse pregnancy outcomes are reported among Somali born refugees in high-income countries. The aim of this study was to explore experiences and perceptions on war, violence, and reproductive health before migration among Somali born women in Sweden.

Method: Qualitative semi-structured individual interviews were conducted with 17 Somali born refugee women of fertile age living in Sweden. Thematic analysis was applied.

Results: Before migration, widespread war-related violence in the community had created fear, separation, and interruption in daily life in Somalia, and power based restrictions limited access to reproductive health services. The lack of justice and support for women exposed to non-partner sexual violence or intimate partner violence reinforced the risk of shame, stigmatization, and silence. Social networks, stoicism, and faith constituted survival strategies in the context of war.

Conclusions: Several factors reinforced non-disclosure of violence exposure among the Somali born women before migration. Therefore, violence-related illness might be overlooked in the health care system. Survival strategies shaped by war contain resources for resilience and

Background: Violence against women is associated with serious health problems, including adverse maternal and child health. Antenatal care (ANC) midwives are increasingly expected to implement the routine of identifying exposure to violence. An increase of Somali born refugee women in Sweden, their reported adverse childbearing health and possible links to violence pose a challenge to the Swedish maternity health care system. Thus, the aim was to explore ways ANC midwives in Sweden work with Somali born women and the questions of exposure to violence.

Methods: Qualitative individual interviews with 17 midwives working with Somali-born women in nine ANC clinics in Sweden were analyzed using thematic analysis.

Results: The midwives strived to focus on the individual woman beyond ethnicity and cultural differences. In relation to the Somali born women, they navigated between different definitions of violence, ways of handling adversities in life and social contexts, guided by experience based knowledge and collegial support. Seldom was ongoing violence encountered. The Somali-born women’s’ strengths and contentment were highlighted, however, language skills were considered central for a Somali-born woman’s access to rights and support in the Swedish society. Shared language, trustful relationships, patience, and networking were important aspects in the work with violence among Somali-born women.

Conclusion: Focus on the individual woman and skills in inter-cultural communication increases possibilities of overcoming social distances. This enhances midwives’ ability to identify Somali born woman’s resources and needs regarding violence disclosure and support. Although routine use of professional interpretation is implemented, it might not fully provide nuances and social safety needed for violence disclosure. Thus, patience and trusting relationships are fundamental in work with violence among Somali born women. In collaboration with social networks and other health care and social work professions, the midwife can be a bridge and contribute to increased awareness of rights and support for Somali-born women in a new society.

Perceptions and experiences of war, violence and migration and related sexual and reproductive health among Somali refugee women in Sweden.

Background and objectives: Sweden has during the latest six years experienced a twofold increase of Somali born refugees. Elevated levels of pregnancy related morbidity and perinatal complications are seen among Somali born refugee women. Research has shown links between a mother´s prenatal stress and anxiety and the health of the child the first year. Furthermore, violence towards a mother-to-be has negative health effects and increases the neonatal mortality The specific aim in the current study was to explore perceptions and experiences of war, violence and migration among Somali refugee women in Sweden. This in order to find strategies in caring for birth giving Somali refugee women, with possible experiences of violence, which would benefit the woman and society at large.

Material and methods: Qualitative individual audio-recorded interviews were conducted with Somali born refugee women in fertile ages. Interviews were held in three steps: 1) personal narratives by newly arrived Somali born women, 2) perceptions and views out of a depersonalized case and 3) reflections upon emerging themes by female key persons of Somali origin. Thematic analysis according to Clarke and Braun was applied.

Preliminary results: The analysis resulted in two main themes: Lives controlled by the presence of violence and Sacrificing for the sake of a future. Access to education, livelihood opportunities and health facilities has been strictly limited by the long-lasting civil war. Escalated violations of sexual and reproductive health and rights were a common triggering factor for finalizing escape. Lives have been extensively marked by family separations. Patience created by war and a pragmatic orientation in life have made survival possible.

Conclusions: To be presented at the congress

Implications for practice: The results will provide increased evidence based knowledge useful to midwives when caring and supporting birth giving refugee women.

Background: Political violence and war are push factors for migration and social determinants of health among migrants. Somali migration to Sweden has increased threefold since 2004, and now comprises refugees with more than 20 years of war experiences. Health is influenced by earlier life experiences with adverse sexual and reproductive health, violence, and mental distress being linked. Adverse pregnancy outcomes are reported among Somali born refugees in high-income countries. The aim of this study was to explore experiences and perceptions on war, violence, and reproductive health before migration among Somali born women in Sweden.

Method: Qualitativesemi-structured individual interviews were conducted with 17 Somali born refugee women of fertile age living in Sweden. Thematic analysis was applied.

Results: Before migration, widespread war-related violence in the community had created fear, separation, and interruption in daily life in Somalia, and power based restrictions limited access to reproductive health services. The lack of justice and support for women exposed to non-partner sexual violence or intimate partner violence reinforced the risk of shame, stigmatization, and silence. Social networks, stoicism, and faith constituted survival strategies in the context of war.

Conclusions: Several factors reinforced non-disclosure of violence exposure among the Somali born women before migration. Therefore, violence-related illness might be overlooked in the health care system. Survival strategies shaped by war contain resources for resilience and enhancement of well-being and sexual and reproductive health and rights in receiving countries after migration.

Background: Political violence is a push factors for migration and social determinants of health among migrants. The Somali migration to Sweden has increased threefold during the latest six years, now comprising refugees with more than 20 years of war experiences. Adverse childbearing health and outcomes are reported among Somali born refugees in high income countries. Health is influenced by earlier life experiences and a link between adverse sexual and reproductive health, violence and mental distress is described in research. Therefore, the aim was to explore experiences and perceptions on war, violence and sexual and reproductive health before migration among Somali born women in Sweden.

Method: Qualitativesemi-structured individual interviews with Somali born refugee women living in Sweden were conducted, based on personal narratives and a hypothetical case. Thematic analysis was applied.

Results: Escalating violence and power based restrictions permeated gradually all aspect of life and limited both access to and quality of reproductive health services in pre-migration Somalia. Formal societal support for women exposed to violence was absent. This reinforced shame and stigma connected to war related and community based sexual violence and the silence surrounding sexual and intimate partner violence. Women expressed survival strategies in the context of war based on social networks, pragmatism, strength and faith.

Conclusions: Lack of formal structures on community levels has together with collective violence negatively impacted the whole spectra of women’s lives which have undermined the sexual and reproductive and health and rights. Several factors reinforce non-disclosure of violence exposure and can thus hamper health care seeking for violence related illness in the receiving country. Survival strategies shaped by war contain resources for resilience and enhancement of mental, sexual and reproductive health in receiving country.

OBJECTIVE: This study aimed to assess women´s acceptability of diagnosis and treatment of incomplete abortion with misoprostol by midwives, compared with physicians.

METHODS: This was an analysis of secondary outcomes from a multi-centre randomized controlled equivalence trial at district level in Uganda. Women with first trimester incomplete abortion were randomly allocated to clinical assessment and treatment with misoprostol by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and stratified for health care facility. Acceptability was measured in expectations and satisfaction at a follow up visit 14-28 days following treatment. Analysis of women's overall acceptability was done using a generalized linear mixed-effects model with an equivalence range of -4% to 4%. The study was not masked. The trial is registered at ClinicalTrials.org, NCT 01844024.

RESULTS: From April 2013 to June 2014, 1108 women were assessed for eligibility of which 1010 were randomized (506 to midwife and 504 to physician). 953 women were successfully followed up and included in the acceptability analysis. 95% (904) of the participants found the treatment satisfactory and overall acceptability was found to be equivalent between the two study groups. Treatment failure, not feeling calm and safe following treatment, experiencing severe abdominal pain or heavy bleeding following treatment, were significantly associated with non-satisfaction. No serious adverse events were recorded.

CONCLUSIONS: Treatment of incomplete abortion with misoprostol by midwives and physician was highly, and equally, acceptable to women.

Unsafe abortion in Africa continues to be a major contributor to the global maternal mortality which affects young women in particular. In Uganda, where abortion is legally restricted and stigmatised, unsafe abortion is a major public health issue. We explored reproductive agency in relation to unsafe abortion among young women seeking post-abortion care. Through in-depth interviews we found that reproductive agency was constrained by gender norms and power imbalances and strongly influenced by stigma. Lack of resources and the need for secrecy resulted in harmful abortion practices and delayed care-seeking. Women did not claim ownership of the abortion decision, but the underlying meaning in the narratives positioned abortion as an agentive action aiming to regain control over one's body and future. Women's experiences shaped contraceptive intentions and discourse, creating a window of opportunity that was often missed. This study provides unique insight into how young women negotiate and enact reproductive agency in Uganda. Health systems need to strengthen their efforts to meet young women's sexual and reproductive health needs and protect their rights. Enabling young women's agency through access to safe abortion and contraception is paramount.

This paper presents an initiative to revive the previous Somali-Swedish Research Cooperation, which started in 1981 and was cut short by the civil war in Somalia. A programme focusing on research capacity building in the health sector is currently underway through the work of an alliance of three partner groups: six new Somali universities, five Swedish universities, and Somali diaspora professionals. Somali ownership is key to the sustainability of the programme, as is close collaboration with Somali health ministries. The programme aims to develop a model for working collaboratively across regions and cultural barriers within fragile states, with the goal of creating hope and energy. It is based on the conviction that health research has a key role in rebuilding national health services and trusted institutions.

Introduction: The objective of this study was to compare ever-in life contraception use, use of contraception at current conception, and planned use of contraception after an induced abortion, among three groups of women: migrants, second-generation migrants and non-migrant women, and to compare the types of contraception methods used and intended for future use among the three groups of women. Methods: The cross-sectional study administered a questionnaire face-to-face to women aged 18 years and older who were seeking abortion care at one of six abortion clinics in Stockholm County from January to April 2015. Results: The analysis included 637 women. Migrants and second-generation migrants were less likely to have used contraception historically, at the time of the current conception, and to plan to use contraception after their induced abortion compared with non-migrant women. Historically, non-migrants had used pills (89%) and withdrawal (24%) while migrants had used the copper intrauterine device (24%) to a higher extent compared to the other two groups of women. Both the migrants (65%) and second-generation migrants (61%) were more likely than the non-migrants (48%) to be planning to use long-acting reversible contraception. Conclusions: Lower proportions of contraception use were found in migrants and second-generation migrants than in non-migrants. In addition, there were significant differences in the types of contraception methods used historically and intended for future use.

To record the variation of perceptions of midwifery faculty in terms of the possibilities and challenges related to the completion of their first online master's level programme in Sexual and Reproductive Health and Rights in Somaliland. The informants included in this phenomenongraphical focus group study were those well-educated professional women and men who completed the master's program. The informant perceived that this first online master's level programme provided tools for independent use of the Internet and independent searching for evidence-based information, enhanced professional development, was challenge-driven and evoked curiosity, challenged professional development, enhanced personal development and challenged context-bound career paths. Online education makes it possible for well-educated professional women to continue higher education. It furthermore increased the informants' confidence in their use of Internet, software and databases and in the use of evidence in both their teaching and their clinical practice. Programmes such as the one described in this paper could counter the difficulties ensuring best practice by having a critical mass of midwives who will be able to continually gather contemporary midwifery evidence and use it to ensure best practice. An increase of online education is suggested in South-central Somalia and in similar settings globally.

Background. High quality maternal health care is an important tool to reduce maternal and neonatal mortality. Services offered should be evidence based and adapted to the local setting. This qualitative descriptive study explored the perspectives and experiences of midwives, assistant physicians and medical doctors on the content and quality of maternal health care in rural Vietnam.

Method. The study was performed in a rural district in northern Vietnam. Four focus group discussions with health care professionals at primary health care level were conducted. The data was analysed using qualitative manifest and latent content analysis.

Result. Two main themes emerged: "Contextual conditions for maternal health care" and "Balancing between possibilities and constraints". Contextual conditions influenced both pregnant women's use of maternal health care and health care professionals' performance. The study participants stated that women's uses of maternal health care were influenced by economical constraints and cultural norms that impeded their autonomy in relation to childbearing. Structural constraints within the health care system included inadequate financing of the primary health care, resulting in lack of human resources, professional re-training and adequate equipment.

Conclusion. Contextual conditions strongly influenced the performance and interaction between pregnant women and health care professionals within antenatal care and delivery care in a rural district of Vietnam. Although Vietnam is performing comparatively well in terms of low maternal and child mortality figures, this study revealed midwives' and other health care professionals' perceived difficulties in their daily work. It seemed maternal health care was under-resourced in terms of staff, equipment and continuing education activities. The cultural setting in Vietnam constituting a strong patriarchal society and prevailing Confucian norms limits women's autonomy and reduce their possibility to make independent decisions about their own reproductive health. This issue should be further addressed by policy-makers. Strategies to reduce inequities in maternal health care for pregnant women are needed. The quality of client-provider interaction and management of pregnancy may be strengthened by education, human resources, re-training and provision of essential equipment.

Objective. Women’s understanding of pregnancy and antenatal care is influenced by their cultural context. In low income settings women may have limited influence over their reproductive health including when to seek health care. Awareness of signs of pregnancy complications is essential to seek timely care. The use of antenatal care services in Vietnam has been studied with quantitative methods but there are few qualitative studies on the perceptions of pregnancy and maternal health care among Vietnamese women.

Design. Four focus group discussions (FGD) with pregnant women were performed.

Setting. The study was conducted in a rural district in northern Vietnam.

Population. Pregnant women in the last trimester living in Bavi district, Vietnam.

Method. The data were analysed using manifest and latent content analysis.

Result. The latent theme ‘Securing pregnancy during normal course and at deviation’, consisting of the main categories ‘Ensuring a healthy pregnancy’ and ‘Separating the normal from the abnormal’ emerged.

Conclusion. This qualitative study of pregnant women in rural Vietnam indicates how women create a strategy to promote a healthy pregnancy through lifestyle adjustments, gathering of information, and seeking timely medical care. Insight in pregnancy-related conditions were sought from various sources and influenced both by Vietnamese traditions and modern medical knowledge. Public knowledge about deviating symptoms during pregnancy and high confidence in maternal health care are most likely contributing factors to the relative good maternal health status in Vietnam.

Population-based estimations of perinatal and neonatal outcomes are sparse in Vietnam. There are no previously published data on small for gestational age (SGA) infants. A rural population in northern Vietnam was investigated from 1999 to 2005 (n = 5521). Based on the birthweight distributions within the population under study, reference curves for intrauterine growth for Vietnamese infants were constructed and the prevalence and distribution of SGA was calculated for each sex. Neonatal mortality was estimated as 11.6 per 1000 live births and the perinatal mortality as 25.0 per 1000 births during the study period. The mean birthweight was 3112 g and the prevalence of low birthweight was 5.0%. The overall prevalence of SGA was 6.4%. SGA increased with gestational age and was 2.2%, 4.5% and 27.1% for preterm, term and post-term infants, respectively. Risk factors for SGA were post-term birth: adjusted odds ratio (AOR) 7.75 [95% CI 6.02, 9.98], mothers in farming occupations AOR 1.72 [95% CI 1.21, 2.45] and female infant AOR 1.61 [95% CI 1.27, 2.03]. There was a pronounced decrease in neonatal mortality after 33 weeks of gestation. Suggested interventions are improved prenatal identification of SGA infants by ultrasound investigation for fetal growth among infants who do not follow their expected clinical growth curve at the antenatal clinic. Other suggestions include allocating a higher proportion of preterm deliveries to health facilities with surgical capacity and neonatal care.

Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Department of Women's and Children's Health, Karolinska Institutet, School of Social and Health Science, Dalarna University, Falun, Sweden.

Objectives. This study aimed to investigate the knowledge, attitudes and perceptionstowards contraceptive use and counselling among medical students in Maharashtra, India.

Setting. Considerable global maternal mortality and morbidity could be avoided through theuse of effective contraception. In India, contraception services are frequently unavailable or there are obstacles to obtaining modern, reversible contraceptives.

Participants. A cross-sectional descriptive study using a self-administered questionnaire was conducted among 1996 medical students in their fifth year of study at 27 medical colleges in the state of Maharashtra, India. Descriptive and analytical statistics interpreted the survey instrument and significant results were presented with 95% CI.

Results. Respondents expressed a desire to provide contraceptive services. A few studentshad experienced training in abortion care. There were misconceptions about moderncontraceptive methods and the impact of sex education. Attitudes towards contraceptionwere mainly positive, premarital counselling was supported and the influence of traditional values and negative provider attitudes on services was recognised. Gender, area of upbringing and type of medical college did not change the results.

Conclusions. Despite mostly positive attitudes towards modern contraceptives, sex education and family planning counselling, medical students in Maharashtra have misconceptions about modern methods of contraception. Preservice and in-service training in contraceptive counselling should be implemented in order to increase women's access to evidence-based maternal healthcare services.

The aim of this study is to explore women's experiences and perceptions of home use of misoprostol and of the self-assessment of the outcome of early medical abortion in a low-resource setting in India. In-depth interviews were conducted with 20 women seeking early medical abortion, who administered misoprostol at home and assessed their own outcome of abortion using a low-sensitivity pregnancy test. With home use of misoprostol, women were able to avoid inconvenience of travel, child care, and housework, and maintain confidentiality. The use of a low-sensitivity pregnancy test alleviated women's anxieties about retained products. Majority said they would prefer medical abortion involving a single visit in future. This study provides nuanced understanding of how women manage a simplified medical abortion in the context of low literacy and limited communication facilities. Service delivery guidelines should be revised to allow women to have medical abortion with fewer visits.

Background: The need for multiple clinical visits remains a barrier to women accessing safe legal medical abortion services. Alternatives to routine clinic follow-up visits have not been assessed in rural low-resource settings. We compared the effectiveness of standard clinic follow-up versus home assessment of outcome of medical abortion in a low-resource setting.

Methods: This randomised, controlled, non-inferiority trial was done in six health centres (three rural, three urban) in Rajasthan, India. Women seeking early medical abortion up to 9 weeks of gestation were randomly assigned (1:1) to either routine clinic follow-up or self-assessment at home. Randomisation was done with a computer-generated randomisation sequence, with a block size of six. The study was not blinded. Women in the home-assessment group were advised to use a pictorial instruction sheet and take a low-sensitivity urine pregnancy test at home, 10-14 days after intake of mifepristone, and were contacted by a home visit or telephone call to record the outcome of the abortion. The primary (non-inferiority) outcome was complete abortion without continuing pregnancy or need for surgical evacuation or additional mifepristone and misoprostol. The non-inferiority margin for the risk difference was 5%. All participants with a reported primary outcome and who followed the clinical protocol were included in the analysis. This study is registered with ClinicalTrials.gov, number NCT01827995.

Findings: Between April 23, 2013, and May 15, 2014, 731 women were recruited and assigned to clinic follow-up (n=366) or home assessment (n=365), of whom 700 were analysed for the main outcomes (n=336 and n=364, respectively). Complete abortion without continuing pregnancy, surgical intervention, or additional mifepristone and misoprostol was reported in 313 (93%) of 336 women in the clinic follow-up group and 347 (95%) of 364 women in the home-assessment group (difference -2.2%, 95% CI -5.9 to 1.6). One case of haemorrhage occurred in each group (rate of adverse events 0.3% in each group); no other adverse events were noted. Interpretation Home assessment of medical abortion outcome with a low-sensitivity urine pregnancy test is non-inferior to clinic follow-up, and could be introduced instead of a clinic follow-up visit in a low-resource setting.

Background: Somalia is one of 13 countries in Africa with stillbirth rates of more than 30 per 1000 total birth. To our knowledge no study in Somaliland has focused on the mother-baby dyad regarding risk factors for stillbirth. The objective of this study was to identify frequency, causes and beliefs for stillbirth in mothers with life threatening conditions as a pilot for a potential nationwide near-miss study with full coverage in the Somaliland health care system.Method: A prospective cross sectional study using the WHO near-miss questionnaire in a tertiary level hospital with 1.385 deliveries during a five months period in 2015.Results: Out of 138 near miss and death events 22% (n=30) had a stillbirth. Seventy-seven percent (77%) of the mothers (n=23) with stillborn babies survived and 23% died (n=7). They were diagnosed with life threatening conditions, possible to prevent, on arrival at the tertiary hospital. None of them developed the maternal complication/s during the hospital stay. Cesarean sections (43%) were performed within three hours after arrival. Beliefs regarding the stillbirth for the near miss women were that holding the baby born death helps them cope with the loss (74%) and that religious believes helps them cope faster with the loss (91%).Conclusion and clinical implications: The near miss women, their families, TBAs and SBAs might need better information of what causes a stillbirth, how they could prevent it and about the near miss women’s beliefs surrounding stillbirth to enable them to communicate this to pregnant women and prevent delay in admission to the tertiary level hospital. Furthermore, this pilot study suggest that the “Near Miss Questionnaire” could be used in low-and middle income settings to detect a full picture of the situation with stillbirth in a country.

Background: The number of childbearing adolescents in Vietnam is relatively low but they are more prone to experience adverse outcome than adult women. Reports of increasing rates of abortion and prevalence of STIs including HIV among youth indicate a need to improve services and counselling for these groups. Midwives are key persons in the promotion of young people’s sexual and reproductive health in Vietnam. Aim: The overall aim of this thesis is to describe the prevalence and outcome of adolescent pregnancies in Vietnam (I), to explore the social context and health care seeking behavior of pregnant adolescents (II), as well as to explore the perspectives of health care providers and midwifery students regarding adolescent sexuality and reproductive health service needs (III, IV). Methods: The studies were conducted from 2002 to 2005, combining qualitative and quantitative research methods. A population based prospective survey was used to estimate rates and outcomes of adolescent pregnancies (I). Pregnant and newly delivered adolescents’ experiences of childbearing and their encounters with health care providers were studied using qualitative interviews (II). Health care providers’ perspective on adolescent sexual and reproductive health (ASRH) and views on how to improve the quality of abortion care was explored in focus group discussions (FGD). The values and attitudes of midwifery students about ASRH were investigated using questionnaires and interviews (IV). Descriptive statistics was used to analyse quantitative data (I, IV) and content analysis were applied for qualitative data (II, III, and IV). Findings: Adolescent birth rate was similar to previously reported in Vietnam but lower when compared to other Asian countries. The incidence of stillborn among adolescents was higher than for women in higher reproductive ages. The proportion of preterm deliveries was 20 % of all births, higher than previous findings from Vietnam. About 2 % of the deliveries were home deliveries, more common among women with low education, belonging to ethnic minority and/or living in mountainous areas (I). Ambivalence facing motherhood, pride and happiness but also worries and lack of self-confidence emerged as themes from the interviews; and experience of ‘being in the hands of others’ in a positive, caring sense but also in a sense of subordination in relation to husband, family and health care providers (II). Health care providers at abortion clinics and midwifery students generally disapproved of pre-marital sex, but had a pragmatic view on the need for contraceptive services and counselling to reduce the burden of unwanted pregnancies and abortions for young women. Providers and midwifery students expressed a need for training on ASRH issues (III, IV). Conclusion: Cultural norms and gender inequity make pregnant adolescent women in Vietnam vulnerable to sexual and reproductive health risks. Health care providers experience ethical dilemmas while counselling unmarried adolescents who come for abortion and this has a negative impact on the quality of care. Integrated ASRH in education and training programmes for health care providers, including midwives, as well as continued in-service training on these issues are suggested to improve reproductive health care services in Vietnam.

Universal access to comprehensive abortion care (CAC) is a reproductive right and is essential to reduce preventable maternal mortality and morbidity. In East Africa, abortion rates are consistently high, and the vast majority of all abortions are unsafe, significantly contributing to unnecessary mortality and morbidity. The current debate article reflects and summarises key action points required to continue to speed the implementation of and expand access to CAC in the East, Central, and Southern African (ECSA) health community. To ensure universal access to quality CAC, a regional platform could facilitate the sharing of best practices and successful examples from the region, which would help to visualise opportunities. Such a platform could also identify innovative ways to secure women's access to quality care within legally restrictive environments and would provide information and capacity building through the sharing of recent scientific evidence, guidelines, and training programmes aimed at increasing women's access to CAC at the lowest effective level in the healthcare system. This type of infrastructure for exchanging information and developing co-creation could be crucial to advancing the Sustainable Development Goals 2030 agenda.

Male partners' involvement in women's sexual and reproductive health has been increasingly emphasised in international health. A qualitative approach with open-ended qualitative interviews was used to explore young, married men's first time experiences of early childbearing, their sexual and reproductive decision making and the meanings they make of their role as husbands and fathers. The results offer a nuanced picture of the men's vulnerability in becoming young fathers and having to assume their role as family decision-makers, while still being inexperienced in matters related to the health of their wives and newborn child. Constraints to gender equality and traditional norms and values continue to pose barriers to both young men and women making independent decisions in relation to marriage and childbearing. Men's involvement is necessary in healthcare programmes designed to improve women's sexual and reproductive health and the health of the newborn. Young, first-time fathers, in particular, need support and empowerment.

This study explores married Vietnamese adolescents' perceptions and experiences related to transition into motherhood and their encounter with health care service. In-depth interviews were conducted with 22 women younger than 20 who were either pregnant or had newly delivered. It emerged from the narratives that young women experienced ambivalence in the transition to motherhood in that they felt too young but also happy to be able to please their husband and the extended family. Patterns were shown indicating that the participants experienced lacking power with regard to decisions in relation to pregnancy, delivery, and contraceptive usage. Feelings of being patronized and ignored in the encounter with health care providers were seen in the narratives. Findings might be used for reproductive health care providers, social workers, and educators in their contact with young mothers to empower them to make their own decisions with regard to marriage, childbearing, and contraception.

BACKGROUND: Misoprostol is established for the treatment of incomplete abortion but has not been systematically assessed when provided by midwives at district level in a low-resource setting. We investigated the effectiveness and safety of midwives diagnosing and treating incomplete abortion with misoprostol, compared with physicians.

METHODS: We did a multicentre randomised controlled equivalence trial at district level at six facilities in Uganda. Eligibility criteria were women with signs of incomplete abortion. We randomly allocated women with first-trimester incomplete abortion to clinical assessment and treatment with misoprostol either by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and was stratified for study site. Primary outcome was complete abortion not needing surgical intervention within 14-28 days after initial treatment. The study was not masked. Analysis of the primary outcome was done on the per-protocol population with a generalised linear-mixed effects model. The predefined equivalence range was -4% to 4%. The trial was registered at ClinicalTrials.gov, number NCT01844024.

FINDINGS: From April 30, 2013, to July 21, 2014, 1108 women were assessed for eligibility. 1010 women were randomly assigned to each group (506 to midwife group and 504 to physician group). 955 women (472 in the midwife group and 483 in the physician group) were included in the per-protocol analysis. 452 (95·8%) of women in the midwife group had complete abortion and 467 (96·7%) in the physician group. The model-based risk difference for midwife versus physician group was -0·8% (95% CI -2·9 to 1·4), falling within the predefined equivalence range (-4% to 4%). The overall proportion of women with incomplete abortion was 3·8% (36/955), similarly distributed between the two groups (4·2% [20/472] in the midwife group, 3·3% [16/483] in the physician group). No serious adverse events were recorded.

INTERPRETATION: Diagnosis and treatment of incomplete abortion with misoprostol by midwives is equally safe and effective as when provided by physicians, in a low-resource setting. Scaling up midwives' involvement in treatment of incomplete abortion with misoprostol at district level would increase access to safe post-abortion care.

FUNDING: The Swedish Research Council, Karolinska Institutet, and Dalarna University.

Background Pregnancy outcomes in the general population are important public health indicators. Purpose The overall aim of this study was to investigate the outcomes of reported pregnancies within a well-defined population, to identify risk groups for adverse pregnancy outcomes, and to suggest preventive measures. Method A prospective population-based cohort study of pregnant women in Bavi district, Vietnam between 1 January 1999 and 30 June 2004. Results Pregnancy outcome was reported for 5,259 cases; 4,152 (79%) resulted in a live birth, 67 (1.3%) in a stillbirth, 733 (14%) in an induced abortion, and 282 (5.4%) in a spontaneous abortion. There was an increased risk of home delivery for women from ethnic minorities (OR?=?1.85; 95%CI?=?1.06–3.24) or with less than 6 years of schooling (OR?=?7.36; 95%CI?=?3.54–15.30). The risk of stillbirth was increased for ethnic minorities (OR?=?6.34; 95%CI?=?1.33–30.29) and women delivering at home (OR?=?6.81; 95%CI?=?2.40–19.30). The risk of induced abortion increased with maternal age. Conclusion Our findings emphasize the public health significance of access to adequate family planning, counselling, and maternal health care for all women. Policies should specifically target women from high-risk groups.

Objective. To describe birth rates and pregnancy outcomes, specifically stillbirth, preterm delivery and low birth weight (LBW) in relation to socio-demographic characteristics, among adolescent women in a rural district in northern Vietnam.

Material and method. Within an epidemiological field laboratory, quarterly surveillance of 7767 adolescent women in the ages 15–19 during the period January 1999 to December 2005 was conducted. Birth rates were calculated and pregnancy outcomes were described in relation to background factors.

Result. A total of 1021 pregnancies were reported by 926 adolescent women during the period of whom 17% were below 18years. The estimated adolescent birth rate during 1999–2005 was 27/1000 women-years. The incidence of stillbirth among all births was 19/1000 births. These were more likely to be delivered preterm. The incidence of preterm deliveries and LBW infants was 193 and 75 per 1000 live births, respectively. There were no differences in socio-demographic background for stillbirth, preterm delivery or LBW.

Conclusion. Adolescent birth rates were similar to those found in the recent Vietnamese DHS and considerably lower than the average for South-East Asia. Higher rates of stillbirth and preterm delivery were found than those previously reported for Vietnam, indicating the need for careful monitoring of adolescent pregnancies and their infants. Further research is needed to explore if and how much socio-demographic variables influence pregnancy outcome, comparing more differentiated groups, as a basis for interventions to assure access to adequate reproductive health care services for all women.

The aim of this study is to explore midwifery educators’ expected outcomes in the net-based master's programme, the programmes’ realised outcomes and the reported difference regarding the increased choices for the graduates and the effect on their agency.

Design

In this case study, we focused on a net-based master's programme in sexual and reproductive health in Somalia. Somalia suffers from a shortage of skilled birth attendants and there is a need for building up the capacity of midwifery educators.

Setting and participants

Data was collected in focus group discussions at the start of the programme and eight months after the students graduated. The data were analysed through the lens of the choice framework, which is based on the capability approach.

Findings

Findings show that many of the graduates’ expectations were met, while some were more difficult to fulfil. While the midwives’ choices and resource portfolios had improved because of their role as educators, the social structure prevented them from acting on their agency, specifically in regards to making changes at the social level. Several of the positive developments can be attributed to the pedagogy and structure of the programme.

Conclusion

The flexibility of net-based education gave the midwifery educators a new educational opportunity that they previously did not have. Students gained increased power and influence on some levels. However, they still lack power in government organisations where, in addition to their role as educators, they could use their skills and knowledge to change policies at the social level.

Background: Vietnam has one of the highest abortion rates in the world and adolescent abortions are thought to constitute at least one third of all cases. Lack of balanced reproductive health information and services to adolescents and negative social attitudes towards adolescent sexuality are contributing factors to the high abortion rates. Health providers are important in guiding and counselling adolescents on how to protect their reproductive health. There is a lack of studies on health providers’ perspectives on their work in adolescent reproductive health care. Aim: To explore the perspectives of midwives and doctors on adolescent sexuality and abortion, and what they considered to be quality abortion care for adolescents and the barriers to it, as well as to their own training needs. Methods: Observations of care in abortion clinics and focus group discussions (FGD) were used to collect data. Doctors and midwives from three health care facilities in Quang Ninh province in Northern Vietnam participated in a total of eight FGDs. Data were analysed using latent content analysis.

Findings: Major barriers identified for quality abortion care were of technical and managerial nature. Participants considered that counselling unmarried clients in connection with abortion should focus on warning against the risks and dangers of abortion and pre-marital sexual relations, which they strongly disapproved of. However, they also expressed a pragmatic and caring attitude towards the unmarried girls and couples coming for abortion. Adolescent sexuality and abortion are morally sensitive issues in the Vietnamese culture. The contradictions between cultural norms and the reality facing health providers while counselling the unmarried adolescents need to be addressed in education and training programmes.

Adolescent’s sexuality and related reproductive health and rights problems are sensitive issues in Vietnam. Globalisation has had an impact on the lifestyles of young people, and rising numbers of abortion and STI/HIV risks among youth are posing major health concerns in the country. These problems need to be addressed. Midwives belong to a key category of health personnel in Vietnam, whose task it is to promote adolescents’ sexual and reproductive health and prevent reproductive ill health. It is important to understand future midwives’ perceptions and attitudes in order to improve their education and training programmes. Aim: The aim of this study was to investigate Vietnamese midwifery students’ values and attitudes towards adolescent sexuality, abortion and contraception and their views on professional preparation. Methods: A quantitative survey including 235 midwifery students from four different secondary medical colleges in northern Vietnam was carried out in 2003. A qualitative study addressing similar questions was performed and 18 midwifery students were individually interviewed. Findings: Findings revealed a general disapproval of adolescent pre-marital sexual relations and abortion – ‘an ethics of justice’ - but also an empathic attitude and willingness to support young women, who bear the consequences of unwanted pregnancies and social condemnation – ‘an ethics of care’. Gender-based imbalance in sexual relationships, limited knowledge about reproductive health issues among youth, and negative societal attitudes were concerns expressed by the students. The students saw their future tasks mainly related to childbearing and less to other reproductive health issues, such as abortion and prevention of STI/HIV. Conclusion: Midwifery education in Vietnam should encourage value-reflective thinking around gender inequality and ethical dilemmas, in order to prepare midwives to address adolescents’ reproductive health needs.

Health care providers' experiences of the specific needs among non-European, immigrant women are not openly discussed, although they are acknowledged. To achieve equitable access to sexual and reproductive health (SRH), health care providers need to be better equipped when encountering immigrant women in abortion care, especially regarding contraceptive counselling. The potential impact of patients' knowledge, norms and values is not adequately dealt with in the clinical encounter. Moreover, to provide patient-centred care, it is crucial to understand how to develop and implement SRH care that ensures equal access to high-quality care.

Background: Ugandan law prohibits abortion under all circumstances except where there is a risk for the woman's life. However, it has been estimated that over 250 000 illegal abortions are being performed in the country yearly. Many of these abortions are carried out under unsafe conditions, being one of the most common reasons behind the nearly 5000 maternal deaths per year in Uganda. Little research has been conducted in relation to societal views on abortion within the Ugandan society. This study aims to analyze the discourse on abortion as expressed in the two main daily Ugandan newspapers.

Method: The conceptual content of 59 articles on abortion between years 2006-2012, from the two main daily English-speaking newspapers in Uganda, was studied using principles from critical discourse analysis.

Results: A religious discourse and a human rights discourse, together with medical and legal sub discourses frame the subject of abortion in Uganda, with consequences for who is portrayed as a victim and who is to blame for abortions taking place. It shows the strong presence of the Catholic Church within the medial debate on abortion. The results also demonstrate the absence of medial statements related to abortion made by political stakeholders.

Conclusions: The Catholic Church has a strong position within the Ugandan society and their stance on abortion tends to have great influence on the way other actors and their activities are presented within the media, as well as how stakeholders choose to convey their message, or choose not to publicly debate the issue in question at all. To decrease the number of maternal deaths, we highlight the need for a more inclusive and varied debate that problematizes the current situation, especially from a gender perspective.

Background: Perineal injury is a serious complication of vaginal delivery that has a severe impact on the quality of life of healthy women. The prevalence of perineal injuries among women who give birth in hospital has increased over the last decade, while it is lower among women who give birth at home. The aim of this study was to describe the practice of midwives in home birth settings with the focus on the occurrence of perineal injuries.

Methods: Twenty midwives who had assisted home births for between one and 29 years were interviewed using an interview guide. The midwives also had experience of working in a hospital delivery ward. All the interviews were tape-recorded and transcribed. Content analysis was used.

Results: The overall theme was "No rushing and tearing about", describing the midwives' focus on the natural process taking its time. The subcategories 1) preparing for the birth; 2) going along with the physiological process; 3) creating a sense of security; 4) the critical moment and 5) midwifery skills illuminate the management of labor as experienced by the midwives when assisting births at home.

Conclusions: Midwives who assist women who give birth at home take many things into account in order to minimize the risk of complications during birth. Protection of the woman's perineum is an act of awareness that is not limited to the actual moment of the pushing phase but starts earlier, along with the communication between the midwife and the woman.

AIM: The aim was to explore contraceptive uptake, associated factors and satisfaction among post abortion-care (PAC) seeking women in Kenya. Due to unsafe abortions, almost 120 000 Kenyan women received PAC in 2012, and of these women, 70% did not use contraception before pregnancy.

METHODS: This study was nested in a larger randomised controlled trial, where 859 women sought PAC at two public hospitals in Kisumu, in June 2013-May 2016. The women were randomly assigned to a midwife or a physician for PAC, including contraceptive counselling, and followed up at 7-10 days and three months. Associated factors for contraceptive uptake were analysed with binary logistic regression, and contraceptive method choice, adherence and satisfaction level were examined by descriptive statistics, using IBM SPSS Statistics for Windows, Version 22.0.

CONCLUSIONS: PAC-seeking women seem highly motivated to use contraceptives, yet a quarter decline the use, and at 3-month follow-up a further quarter among the users had discontinued. Implant, IUD and permanent method are rarely used. Strategies to improve contraceptive counselling, particularly to adolescent girls, and to increase access to a wide range of methods, as well as provider training and supervision may help to improve contraceptive acceptance and compliance among PAC-seeking women in Kisumu, Kenya.

DESIGN: A multicentre randomised controlled equivalence trial. The study was not masked.

SETTINGS: Gynaecological departments in two hospitals in a low-resource setting, Kenya.

POPULATION: Women (n=1094) with incomplete abortion in the first trimester, seeking PAC between 1 June 2013 to 31 May 2016. Participants were randomly assigned to receive treatment from midwives or physicians. 409 and 401 women in the midwife and physician groups, respectively, were included in the per-protocol analysis.

INTERVENTIONS: 600 µg misoprostol orally, and contraceptive counselling by a physician or midwife.

MAIN OUTCOME MEASURES: Complete abortion not needing surgical intervention within 7-10 days. The main outcome was analysed on the per-protocol population with a generalised estimating equation model. The predefined equivalence range was -4% to 4%. Secondary outcomes were analysed descriptively.

RESULTS: The proportion of complete abortion was 94.8% (768/810): 390 (95.4%) in the midwife group and 378 (94.3%) in the physician group. The proportion of incomplete abortion was 5.2% (42/810), similarly distributed between midwives and physicians. The model-based risk difference for midwives versus physicians was 1.0% (-4.1 to 2.2). Most women felt safe (97%; 779/799), and 93% (748/801) perceived the treatment as expected/easier than expected. After contraceptive counselling the uptake of a contraceptive method after 7-10 days occurred in 76% (613/810). No serious adverse events were recorded.

CONCLUSIONS: Treatment of incomplete abortion with misoprostol provided by midwives is equally effective, safe and accepted by women as when administered by physicians in a low-resource setting. Systematically provided contraceptive counselling in PAC is effective to mitigate unmet need for contraception.

E-learning has become one of the primary ways of delivering education around the globe. In Somalia, which is a country torn within and from the global community by a prolonged civil war, University of Hargeisa has in collaboration with Dalarna University in Sweden adopted, for the first time, e-learning. This study explores barriers and facilitators to e-learning usage, experienced by students in Somalia’s higher education, using the University of Hargeisa as case study. Interviews were conducted with students to explore how University of Hargeisa’s novice users perceived elearning, and what factors positively and negatively affected their e-learning experiences. The Unified Theory of Acceptance and Use of Technology (UTAUT) model was used as a framework for interpreting the results. The findings show that, in general, the students have a very positive attitude towards e-learning, and they perceived that e-learning enhanced their educational experience. The communication aspect was found to be especially important for Somali students, as it facilitated a feeling of belonging to the global community of students and scholars and alleviated the war-torn country’s isolation. However, some socio-cultural aspects of students’ communities negatively affected their e-learning experience. This study ends with recommendations based on the empirical findings to promote the use and enhance the experience of e-learning in post conflict Somali educational institutions

OBJECTIVES: The objectives of this study were to evaluate a culturally tailored parenting support program (Ladnaan) for Somali-born parents and to determine its effectiveness on children’s emotional and behavioral problems.

METHODS: This randomized controlled trial included 120 Somali-born parents with children aged 11 to 16 years. The parents reported self-perceived stress in relation to parenting practices. The intervention consisted of culturally tailored societal information combined with the parenting program Connect. Parents received 12 weeks of intervention, 1 to 2 hours each week, in groups of 12 to 17 parents. Nine group leaders with a Somali background who received a standardized training program delivered the intervention. The primary outcome was a decrease in emotional and behavioral problems based on a Child Behavior Checklist. Parents were randomly allocated either to an intervention group or a wait-list control group. Covariance analyses were conducted according to intention-to-treat principles.

RESULTS: The results showed significant improvement in the children in the intervention group for behavioral problems after a 2-month follow-up. The largest effect sizes according to Cohen’s d were in aggressive behavior (95% confidence interval [CI], 1.06 to 3.07), social problems (95% CI, 0.64 to 1.70), and externalizing problems (95% CI, 0.96 to 3.53).

CONCLUSIONS: The large effect sizes in this study show that this 12-week culturally tailored parenting support program was associated with short-term improvements in children’s behavior. The study adds to the field of parenting interventions by demonstrating how to culturally tailor, engage, and retain parenting programs for immigrant parents.

BACKGROUND: Pre- and post-migration trauma due to forced migration may impact negatively on parents' ability to care for their children. Little qualitative work has examined Somali-born refugees' experiences. The aim of this study is to explore Somali-born refugees' experiences and challenges of being parents in Sweden, and the support they need in their parenting.

METHODS: A qualitative descriptive study was undertaken. Data were collected from four focus group discussions (FGDs) among 23 Somali-born mothers and fathers living in a county in central Sweden. Qualitative content analysis has been applied.

RESULTS: A main category, Parenthood in Transition, emerged as a description of a process of parenthood in transition. Two generic categories were identified: Challenges, and Improved parenting. Challenges emerged from leaving the home country and being new and feeling alienated in the new country. In Improved parenting, an awareness of opportunities in the new country and ways to improve their parenting was described, which includes how to improve their communication and relationship with their children. The parents described a need for information on how to culturally adapt their parenting and obtain support from the authorities.

CONCLUSIONS: Parents experienced a process of parenthood in transition. They were looking to the future and for ways to improve their parenting. Schools and social services can overcome barriers that prevent lack of knowledge about the new country's systems related to parenthood. Leaving the home country often means separation from the family and losing the social network. We suggest that staff in schools and social services offer parent training classes for these parents throughout their children's childhood, with benefits for the child and family.

OBJECTIVES: To evaluate the effectiveness of a culturally tailored parenting support programme on Somali-born parents' mental health and sense of competence in parenting.

DESIGN: Randomised controlled trial.

SETTING: A city in the middle of Sweden.

PARTICIPANTS: Somali-born parents (n=120) with children aged 11-16 years and self-perceived stress in their parenting were randomised to an intervention group (n=60) or a waiting-list control group (n=60).

INTERVENTION: Parents in the intervention group received culturally tailored societal information combined with the Connect parenting programme during 12 weeks for 1-2 hours per week. The intervention consisted of a standardised training programme delivered by nine group leaders of Somali background.

OUTCOME: The General Health Questionnaire 12 was used to measure parents' mental health and the Parenting Sense of Competence scale to measure parent satisfaction and efficacy in the parent role. Analysis was conducted using intention-to-treat principles.

RESULTS: The results indicated that parents in the intervention group showed significant improvement in mental health compared with the parents in the control group at a 2-month follow-up: B=3.62, 95% CI 2.01 to 5.18, p<0.001. Further, significant improvement was found for efficacy (B=-6.72, 95% CI -8.15 to -5.28, p<0.001) and satisfaction (B=-4.48, 95% CI -6.27 to -2.69, p<0.001) for parents in the intervention group. Parents' satisfaction mediated the intervention effect on parental mental health (β=-0.88, 95% CI -1.84 to -0.16, p=0.047).

CONCLUSION: The culturally tailored parenting support programme led to improved mental health of Somali-born parents and their sense of competence in parenting 2 months after the intervention. The study underlines the importance of acknowledging immigrant parents' need for societal information in parent support programmes and the importance of delivering these programmes in a culturally sensitive manner.

With the objective to improve access to safe abortion services in India, the Ministry of Health and Welfare, with approval of the Law Ministry, published draft amendments of the MTP Act on October 29, 2014. Instead of the expected support, the amendments created a heated debate within professional medical associations of India. In this commentary, we review the evidence in response to the current discourse with regard to the amendments. It would be unfortunate if unsubstantiated one-sided arguments would impede the intention of improving access to safe abortion care in India.